Recent data indicate that about 45% of EDs in the United States report being “on diversion” at some point within a given year to alleviate crowding. “Although ambulance diversion has been used for quite some time, several studies link these diversions to negative consequences,” explains M. Kit Delgado, MD, MS. “These include prolonged transport times, delays in care, higher mortality, and lower hospital revenue.” Efforts have been made to reduce ambulance diversion in the past. These strategies include implementing ED patient-flow improvements. “Optimizing front end operations, such as patient triage, registration, and tracking, is also important,” says Dr. Delgado. “Other improvement efforts include adopting hospital-wide full capacity protocols to expedite the transfer of admitted patients from EDs to inpatient units.” New Insights on Diversion & Crowding Questions remain about the strategies that can best reduce diversion without increasing ED crowding and how best to coordinate these efforts. In the Western Journal of Emergency Medicine, Dr. Delgado and colleagues had a study published that systematically reviewed simulation model investigations. “Our overall goal was to gain insights on how to optimally reduce ambulance diversion,” Dr. Delgado says. The analysis identified 10 studies that used simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems. Results showed that ambulance diversion only minimally improved ED waiting room times. Strategies that were found to reduce diversion considerably include: 1. Adding holding units for inpatient boarders. 2. Adding ED-based fast tracks. 3. Improving lab turnaround times. 4. Smoothing out elective surgery caseloads. “The desired effect of reducing ED waiting room times by diverting ambulances is likely to be very small,” says...

The workload for hospitalists has increased significantly, thanks in part to increased residency work-hour restrictions, greater access for patients to healthcare, and a general focus among hospitals to improve patient volume and throughput. Further complicating matters is that hospitalists are adept at functioning in different hospital environments and capacities, which has increased their use and workload. To assess the impact of workload on patient safety and quality measures, my colleagues and I conducted a national survey of hospitalists that was published in JAMA Internal Medicine. Hospitalists Reporting Unsafe Workloads According to our results, about 40% of hospitalists reported that their workload exceeded safe levels (more than 15 patients per shift) at least monthly, and 36% said it happened more than once a week. Approximately one-quarter of respondents reported that excessive workload delayed the admission or discharge of patients until the next shift or hospital day, which in turn impacted length of stay and workloads among ED providers. In addition, 25% of respondents reported that they failed to fully discuss treatment options or to answer questions from patients and family members, and 19% said patient satisfaction soured due to unsafe workloads. Furthermore, 18% reported that it adversely affected patient handoffs. More than 20% of physicians reported that their average workload likely contributed to patient transfers, morbidity, or even mortality. High Hospital Admissions Taking a Toll High levels of admissions and unexpected health changes among admitted patients can dramatically affect the workload of hospitalists and ED physicians. In turn, these changes can increase lengths of stay and clog processes of care in the ED. To overcome these issues, a mutual understanding...

Using an after-hours clinic (AHC) that was off-site from a children’s hospital ED appears to significantly reduce length of stay (LOS) and charges. In a retrospective analysis, researchers found that the average LOS was 81.2 minutes shorter and average charges were $236.20 less for AHC-treated patients when compared with patients treated in a pediatric ED. The researchers reported that this approach may be an effective model to help address ED overcrowding and promote patient safety. Abstract: Pediatric Emergency Care, November...

In previous research, studies have documented significant links between length of stay (LOS) over 24-hour periods and hospital occupancy, the number of ED admissions, and other factors. In the May 2012 Western Journal of Emergency Medicine, my colleagues and I published a study that looked at LOS in more discreet time periods than what earlier analyses have reported. We did this because ED crowding and volume can vary greatly during a given 24-hour period. We wanted to find out which factors were associated with LOS and whether this relationship was present during all or only specific 8-hour shifts. In our analysis, independent variables were measured during three 8-hour shifts. Shift 1 was from 7:00 am to 3:00 pm, shift 2 was from 3:00 pm to 11:00 pm, and shift 3 was from 11:00 pm to 7:00 am. For each shift, the numbers of ED nurses on duty, discharges, discharges on the previous shift, resuscitation cases, admissions and ICU admissions, and LOS on the previous shift, were measured. For each 24- hour period, the numbers of elective surgical admissions and hospital occupancy were measured, since these could not be measured in 8-hour time intervals. ED Length of Stay: Roles of Occupancy & Admissions On all three shifts, LOS increased by about 1 minute for each additional 1% increase in hospital occupancy. The mean hospital occupancy in our study was 94.9%; considering this high level of demand for inpatient beds, even a 1% increase in occupancy can lead to significant delays. The demand for inpatient beds often exceeds 100% capacity during the late morning and early afternoon hours on weekdays. To...

According to national surveys conducted from 2001 to 2008, ED crowding appears to be getting worse despite ongoing calls for action. During the study period, ED visit numbers grew 1.9% per year. The average occupancy increased 3.1% per year. While advanced imaging increased 140.0% during the 8 years, the following had large effects on occupancy trends: Use of intravenous fluids and blood tests. Performance of any clinical procedure. Mention of two or more medications. Medicare payer status and patients between the ages of 45 and 64 accounted for small disproportionate increases in occupancy. Abstract: Annals of Emergency Medicine, June 22,...